Sr. Fraud Investigator (SIU)

Responsibilities

The Sr. Fraud Investigator SIU (Special Investigations Unit) assists in the implementation and daily operation of the organization's Compliance and FWA Program and other compliance-related activities for the Company's Medicare Advantage (Part C) and Prescription Drug (Part D) health plan programs to ensure the plan meets the regulatory and compliance requirements of federal and state laws and regulations. The SIU Investigator will be responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The primary responsibility of the SIU Investigator is to investigate medium to highly complex cases of fraud, waste and abuse. In addition, the individual will be responsible to conduct investigations which may include field work to perform interviews and obtain medical records/ and other relevant documentation. The Senior Investigator will also act as subject matter expert in researching and communicating their findings both orally and in writing and will be responsible to report any illegal activities in accordance with all applicable laws. The SIU Investigator is responsible for ensuring the strictest form of confidentiality is applied to all audits and investigations conducted

Job Title: Sr. Fraud Investigator (SIU)

Location: Pearland Administrative Office

Department: Health Plan Admin

Job Type: Full Time

Salary Range: $ 70,204 - $86,731 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

Qualifications

Education

Required: Bachelor's Degree or equivalent experience

Preferred: N/A

Experience

Required: 4+ years' experience in claims examination, adjusting, fraud detection, or investigations in a

healthcare environment.

Preferred: Strong knowledge of Medicare Advantage

Medicare regulations, resources and processes

Strong knowledge of Medicare Claims Processing

CPT/Coding knowledge

License(s)

Required: N/A

Preferred: Health Care Anti-Fraud Associate (HCAFA),

OR

Accredited Health Care Fraud Investigator (AHFI),

OR

CFE - Certified Fraud Examiner credential

Special Skills

Required: Knowledge of Managed Care payment methodologies.

Intermediate level of proficiency in MS Excel and Word.

Intermediate level of knowledge with local, state and federal laws and regulations pertaining to healthcare

fraud.

Experience analyzing and interpreting data to identify trends, patterns, and generate leads for them.

Demonstrated strategic and analytical abilities to review and evaluate information such as claims data,

suspicious patterns and other supporting information related to case allegation.

Preferred: Knowledge of ICD-9/10 HCPS/Revenue codes, insurance terms and policy interpretations.

Prefer knowledge of managed health care business model and processes

Other

Required: Excellent written and verbal communication skills.

Demonstrated ability to effectively communicate regulatory requirements to leadership and staff.

Must be detail oriented and have strong organization and time management skills.

Ability to lead and to work independently, a self-starter, creative thinker with high professional standards and

integrity.

Ability to thrive in a very busy and complex work environment with changing priorities and multiple projects

Preferred: N/A

Working Environment: Office

About Us

Start your career journey and become a part of a community of renowned Healthcare professionals. Kelsey-Seybold Clinic is Houston's fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties. Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner. Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares.

Why Kelsey-Seybold Clinic?

• Medical, Vision, and Dental

• Tuition Reimbursement

• Company Matching 401K

• Employee Reward and Recognition Program

• Paid time off for vacation, sick, and holidays

• Employee Assistance Program

• Continuing Medical Education allowance

Kelsey-Seybold Clinic strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by organizational policy or by federal, state, or local laws unless such distinction is required by law. Kelsey-Seybold is a VEVRAA Federal Contractor and desires priority referrals of protected veterans.